William Herring, M.D.

© 2002

Recognizing
Congestive
Heart Failure

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Congestive Heart Failure
X-ray patterns

 Pulmonary Interstitial Edema

 Pulmonary Alveolar Edema
Congestive Heart Failure
Four Signs of Pulmonary interstitial edema

 Thickening of the interlobular septa

 Kerley B lines
 Peribronchial cuffing
 Wall is normally hairline thin
 Thickening of the fissures
 Fluid in the subpleural space in
continuity with interlobular septa
 Pleural effusions
Left Atrial Pressures
Correlated With Pathologic Findings

Normal 5-10 mm Hg

Cephalization 10-15 mm

Kerley B Lines 15-20

Pulmonary Interstitial Edema 20-25

Pulmonary Alveolar Edema > 25

Kerley B Lines

 B=distended interlobular septa

 Location and appearance
 Bases
 1-2 cm long
 Horizontal in direction
 Perpendicular to pleural surface
Multiple Kerley B lines at
the left lung base
These are faint whites
lines perpendicular to
the pleural surface and
1-2cm long
 Kerley A and C Lines

 A=connective tissue near bronchoarterial

bundle distends with fluid
 Location and appearance
 Near hilum
 Run obliquely
 Longer than B lines
 C=reticular network of lines
 C Lines probably don’t exist
Intersecting
network of lines
are Kerley A lines
in proper clinical
setting
Peribronchial Cuffing

 Bronchial wall is usually not visible

 Interstitial fluid accumulates around bronchi
 Causes thickening of bronchial wall
 When seen on end, looks like little
“doughnuts”
 Meaningful when seen distal to hilar area
Numerous small circular
“doughnuts” seen in
lung represent fluid in
bronchial walls when
seen in conjunction with
other signs of CHF
Fluid in The Fissures

 Fluid collects in the subpleural space

 Between visceral pleura and lung
parenchyma
 Normal fissure is thickness of a
sharpened pencil line
 Fluid may collect in any fissure
 Major, minor, accessory fissures, azygous
fissure
Fluid in the minor fissure
Fissures may be seen
normally but are usually
no thicker than the point
of a sharpened pencil
Pleural Effusion

 Either in the pleural space or subpleural in

location
 Laminar effusions collect beneath visceral
pleura (subpleural)
 In loose connective tissue between lung
and pleura
 Same location as “pseudotumors”
Laminar effusion in CHF
Left Atrial Pressures
Correlated With Pathologic Findings

Normal 5-10 mm Hg

Cephalization 10-15 mm

Kerley B Lines 15-20

Pulmonary Interstitial Edema 20-25

Pulmonary Alveolar Edema > 25

Congestive Heart Failure
Pulmonary alveolar edema

 Fluffy, indistinct patchy densities

 Outer third of lung frequently spared
 Bat-wing or butterfly configuration
 Lower lung zones more affected than
upper
Pulmonary alveolar
edema has a
“butterfly” or “bat-
wing” configuration
Pulmonary Alveolar Edema
Clearing

 Generally clears in 3 days or less

 Resolution usually begins peripherally
and moves centrally
Pulmonary Edema
Types

 Cardiogenic
 Neurogenic
 Increased capillary permeability
 E.g. Allergic reactions
Congestive Heart Failure
Common Causes of

 Coronary artery disease

 Hypertension
 Cardiomyopathy
 Valvular lesions
 AS, MS
 L to R shunts
Congestive Heart Failure
Clinical

 Usually from left heart failure

 Shortness of breath
 Paroxysmal nocturnal dyspnea
 Orthopnea
 Cough
 Right heart failure
 Edema
Important Points

 The four reliable signs of CHF are:

 Kerley B lines
 Fluid in the fissures
 Peribronchial cuffing
 Pleural effusion
 NOT cardiomegaly
 NOT cephalization
Which of the following patients has
CHF?

Click to go forward

Click to go back
Does this patient have CHF?

Yes

No

Go ahead
Does this patient have CHF?

Yes

No

Go ahead
Does this patient have CHF?

Yes

No

Go ahead
Does this patient have CHF?

Yes

No

Go ahead
Correct
This is CHF

 There are
Kerley A
and B lines
at the right
lung base
and a
small right
effusion

Go ahead
Correct
This is CHF

There is
diffuse
airspace
(alveolar)
disease which
has somewhat
of a “bat-wing”
appearance

Go ahead
Correct
There is No CHF
 There are multiple
nodules in both lungs
from metastatic disease

Go ahead
Correct
This is CHF
 There are Kerley B lines
visible at both lung bases

Go ahead
Wrong
Look Again

 Remember to look for the 4 signs of

CHF
 Kerley B lines
 Fluid in the fissures
 Peribronchial cuffing
 Pleural effusion

Go Back
Congratulations, You Graduate

I know
CHF
when I
see it

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